1. Agencies Involved
Education Leeds
NHS Leeds Community Healthcare
Leeds Teaching Hospitals Trust
Leeds Partnership Foundation Trust
West Yorkshire Police
Youth Offending Service, Leeds City Council
HM Prison Service Young Offenders Service
Connexions Leeds
Children and Young People’s Social Care, Leeds City Council
Environments and Neighbourhoods Directorate, Leeds City Council
2. The Independent Overview Report Author:
The Overview Report was compiled by Denis Robinson. He is a qualified Social Worker who had worked for Local Authority Social Services Departments for 28 years before moving to work for a Children’s Voluntary Organisation. His experience includes several senior managerial posts in Children’s Services, including being Director of the Children’s Division of a Local Authority Social Services Department. He has also been Vice–Chair of an Area Child Protection Committee.
The Author had no previous or current professional interests with Leeds Safeguarding Children Board or any of its constituent agencies.
3. Reason for the Report:
This report provides a summary of an Overview Report which was commissioned in accordance with regulation 5(2) (a) & (b)(ii) of The Local Safeguarding Children Boards Regulations 2006 which came into effect on 1 April, 2006. Guidance issued in Chapter 8 of ‘Working Together to Safeguard Children’ (HM Government 2006) has been followed.
This summary is based upon information provided, via the Serious Case Overview Panel, from individual Management Reviews carried out by agencies that provided services to Child N and her family. Any opinions expressed are based on the information available. Conclusions and recommendations are based on analysis of the information provided, with the benefit of hindsight. They are intended to assist in the application of ‘best practices’ for the future and should not be considered as a judicial opinion based on the rigorous level of investigation required in the Civil Courts.
4. Purpose of a Serious Case Review: (Working Together 2006 8.3 – 8.4)
The purpose of a Serious Case Review is to:
4.1 Establish whether there are any lessons to be learnt from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people;
4.2 Identify clearly what those lessons are, how they will be acted on, and what is expected to change as a result;
4.3 As a consequence, improve inter-agency working and better safeguard and promote the welfare of children and young people.
Serious Case Reviews are not enquiries about how a child died or who is culpable. That is a matter for Coroners and Criminal courts, respectively, to determine as appropriate.
5. Terms of Reference for the Overview Report:
5.1 Period of the Review
- The period covered by the SCR was from September 2001 (when the father of Child N commenced high school) up to the point of Child N’s death in March 2008
- Agencies were asked to summarise any significant events / issues and agency involvement with the parents prior to September 2001.
5.2 The Overview Report Terms of Reference were based on Working Together 2006, S(8.28)
- To summarise the circumstances that led to the review being undertaken
- To prepare an overview that summarises what relevant information was known to the agencies and professionals involved about the parents/carers, any perpetrator and the home circumstances of Child N. This should include family background history.
- To undertake an analysis which considers:
- The views of the immediate family (if they indicate a wish to participate)
- How and why events occurred, decisions were made and actions taken or not taken.
- Examples of good practice.
- Opportunities that were taken, or not taken, to identify risks and protective factors in respect of the child.
- Whether, with the benefit of hindsight, different decisions or actions may have led to an alternative course of events.
- Whether the death of Child N was predictable and/or preventable.
- Specific issues identified by the Serious Case Review Panel in relation to this case:
- Whether there was any information available to agencies during the pregnancy that should have prompted a referral to Children & Young People Social Care.
- Whether the school had any indication that the father’s girlfriend was pregnant and what was done with any such information.
- The adequacy of the assessment undertaken at Accident & Emergency one month before the death.
- Issues that have been highlighted in the preparation of Individual Management Reviews indentified by the Serious Case Review Panel which may impact on interagency working.
- In the light of the independent overview author’s analysis, the recommendations contained within individual agency reviews to provide a conclusion which:
- Summarises the lessons to be drawn from the case
- Translates the lessons into recommendations which are SMART (specific, Measurable, Achievable, Achievable, Realistic, Timely)
- To provide an Executive Summary for publication on the LCSB website.
6. Summary of the Case:
6.1 Child N died in early March 2008, aged 4 months, as a result of injuries which included new and old subdural haemorrhages. She had a rib fracture which has been dated as having occurred at least ten days earlier and multiple small bruises that had occurred in the previous for days. The medical view was that child N was the victim of shaken baby syndrome.
6.2 The parents of Child N were arrested and subsequently charged with the offences of Manslaughter and Causing or Allowing the Death of a child contrary to Section 5(1) and (7) of the Domestic Violence, Crime & Victims Act 2004.
6.3 The parents appeared at Crown Court and the father made a guilty plea to a charge of Manslaughter and the mother made a guilty plea to a charge of Causing or Allowing the death of a child. They were later given custodial sentences.
6.4 Child N had been developing normally and meeting her milestones. She was taken to hospital by her parents in early February 2008 and following a thorough examination constipation was diagnosed. No other injuries or concerns were noted at that time. Child N also saw an Orthoptist in mid February for a potential squint. No squint was detected and no other concerns identified.
6.5 The teenage parents of Child N (her father was 16½ and her mother 18 at the time of her birth) lived, following her birth, with her at the child’s maternal grandmother’s home and moved to stay at her paternal grandmother’s home in early 2008.
6.6 The mother had a normal pregnancy and cooperated with health services and Connexions, the latter providing a place on a course for teenage mothers. The mother had left school at 16, after obtaining several GCSE’s and was in employment and training until her pregnancy.
6.7 Child N’s father had had a troubled life. As a young child he had been Looked After by the Local authority for a time, though Children and Young People’s Social Care had not been involved with him since 2000. He had some contact with the Child and Adolescent Mental Health Service in 2002 and 2003. He had emotional and behavioural difficulties, and in 2003 he was excluded from school. He completed his education at a Pupil Referral Unit, though from the autumn of 2005 his attendance had been very poor and he did not attend at all from late 2006. His school were not aware of his girlfriend being pregnant.
6.8 Child N’s father had been a client of the Youth Offending Service almost continually from late 2003 to July 2007. He had been subject of statutory orders arising from offending and in April/May 2007 he spent a period in a Young Offenders Institution.
7. Family Involvement in the Overview Report:
7.1 Following the conclusion of criminal proceedings, the author wrote to the parents and the maternal and paternal grandmothers seeking their involvement in the Serious Case Review. The grandparents did not respond. The mother was seen by the author and she gave her views and opinions on the services that had been provided to her as a young person who was pregnant and also as a young mother. She was positive about some services, particularly a she attended course for teenage mothers. Some of her views informed the recommendations. Child N’s father initially indicated a wish to speak to the author and go on record with his views, but he later decided against this.
8. Conclusions and Lessons to be Learnt:
8.1 Child N died as a result of injuries which have been determined by the Criminal Court to have been inflicted by her father, and in the knowledge of her mother. The Serious Case Review process has considered agency involvement prior to and following her birth. This section of the Executive Summary reports conclusions from the analysis and identifies Lessons to be Learnt.
8.2 The author has not identified significant omissions in the actions of agencies during child N’s brief life that would have directly prevented her death, though hindsight has identified some issues of inter or intra agency working that require improvement.
8.3 Health was the only agency to have face to face contact with child N and her parents following her birth. The parents appeared to have good and appropriate contact with the Health Visitor, GP and hospitals. The indications were that she was developing normally and her parents were providing appropriate care for her and following up concerns that they or others had.
8.4 Several significant failures have been revealed in the practices of agencies prior to child N ’s birth, principally in the services provided to her father. It is reasonable to conclude that if risks had been more accurately assessed and services had been provided more fully and consistently he would have been better prepared for being a parent. It cannot be said that this would have led to a different outcome for child N.
8.5 Significantly the lessons to be learnt from this case relate mainly to the time period before child N’s birth.
8.6 Information Sharing between agencies by front line workers has been identified in this case as an area where there needs to be improvement. The failure to share information has been both between and within agencies. For instance between workers within the Youth Offending Service and the Youth Offending Institution, Youth Offending Service and Education, Connexions and Education and between Connexions and Health. Several examples have been highlighted where information not seen as significant by one person would have been by another had they been aware of the information. The author recognises the challenges of information sharing particularly for agencies whose focus is on the young person/parent rather than the (unborn) child. Managers in such agencies have a responsibility to assist their workers in promoting the sharing information and working together with other agencies where the young person is/is to be a parent.
8.7 Communication within Agencies has been found to be deficient, particularly by the Youth Offending Institute, Education and the Youth Offending Service. These agencies have accepted this and have taken steps to make the improvements required.
8.8 Engaging Parents who struggle to engage with agencies in the best interests of their children is an area that has been identified by Health, Children and Young People Social Care, Youth Offending Service and Education. In this case it relates principally to child N’s paternal grandmother . However, some of the comments made by child N’s mother indicate that she felt some staff from agencies did not engage with her fully. The challenges of engaging ‘reluctant’ parents effectively is a common and recurring issue that should be addressed, at least in part, by good information sharing and interagency co-operation.
8.9 Assessment and Planning gaps have been identified with regard to agencies working with the parents. Agencies all gathered and continued to gather information of a social nature in relation to them. What appears to be a common failure was to consider the information from a safeguarding the child- focused approach. For instance when the pregnancy became known to an agency there was little or no recognition/consideration/assessment of potential safeguarding risk factors for the unborn child that took account of the family’s social circumstances. Risk assessments of various forms exist within agencies involved, however what has been evidenced is that some of these risk assessments can be too narrowly focussed on the core business of the agency and lack a more general awareness and consideration of wider issues that may impact on the safety and wellbeing of a child.
8.10 Recording Keeping has been identified as an issue for several agencies, Youth Offending Service, Education and Connexions in particular. An identified concern has been that some agencies had key information that was not recorded at the time it became known. Agencies accept there are recording issues to be addressed and have already begun to take action.
8.11 Supervision/Management Oversight Standards and arrangements vary between agencies. It is appropriate for each agency to determine what supervision/management oversight arrangements there should be. These arrangements must be robust, ensure accountability and promote reflective practice. Senior managers are responsible for the operation of arrangements that ensure that safeguarding issues are addressed consistently.
8.12 Services available to Teenage Parents are not clearly understood across agencies. Knowledge of the services varied between agencies and front line staff. Information dissemination about the services is identified as an area for improvement . Services for teenage fathers is an area where development is necessary.
9. Recommendations:
9.1 The Independent Overview Report Author endorses the recommendations contained in the reviews submitted by agencies involved in the Serious Case Review and makes the following additional recommendations. Recommendations 5 and 6 have been formulated, in part, as a result of a discussion with child N’s mother.
Recommendations for Leeds Safeguarding Children Board:
Recommendation 1: The Independent Chair of the LSCB should require the Teenage Pregnancy Strategy Co-ordinator to provide (by 30 November 2009) an overview of the current progress of the implementation of the Strategy, with particular reference to services for teenage fathers and age criteria, and to identify any gaps. The LSCB will then determine if further actions are necessary and formulate an action plan.
Recommendation 2: The Independent Chair of the LSCB should ensure (by 31 March 2010) that all agencies have an appropriate procedure and protocol governing the referral to the Teenage Pregnancy Service of all cases when females disclose they are pregnant or males disclose they are to become fathers.
Recommendation 3: The Independent Chair of the LSCB will ensure that all partner agencies involved in this Serious Case Review will (by 31 March 2010) undertake a review of the accuracy and detail of their agencies identification and recording of diversity. Where shortfalls are identified an action plan will be developed to implement required changes.
Recommendation 4: The Independent Chair of the LSCB should ensure (by 31 March 2010) that the LSCB Support Team undertakes sample audits of the returns provided by partner agencies in respect of the information sharing component of Section 11/S157 & S175 and reports the outcomes to the LSCB.
Recommendations for Health Agencies
Recommendation 5: The Chief Executives of the Hospital and Community Health Care Trusts should remind Midwifery and Maternity staff in writing (by 31 December 2009) of the guidance and practice relating to the appropriate engagement of fathers in ante natal, birth and post natal services and appointments.
Recommendation 6: The Chief Executive of the Community Health Care Trust should remind Health Visitors in writing (by 31 December 2009) of the need to ensure that:
(i) There is follow up discussion of leaflets provided.
(ii) Information is gathered in relation to health and welfare issues affecting the child which have occurred between visits and
(iii) Accommodation arrangements for the child/family are confirmed, assessed and reviewed.
Recommendations for Integrated Youth Support Services
Recommendation 7: The Chief Officer of the Integrated Youth Support Services should (by 31 March 2010) seek assurance that case work supervision and managerial oversight provided is of a sufficient standard to enable front-line staff to identify safeguarding issues even though the primary client is the young person/parent.
Recommendation 8: The Chief Officer of the Integrated Youth Support Services should (by 31 March 2010) ensure that the client information database has the capacity to identify (i) teenage parents and partners who are also known to the service and (ii) all clients of Connexions who live at the same address.
Recommendation for Environment and Neighbourhood Services
Recommendation 9: The Chief Housing Services Officer (Environment and Neighbourhood Services) should (by 31 December 2009) improve the standard of case file recording by completing the ongoing review of case file standards in the Homeless Service, identifying shortfalls and making necessary improvements.
Recommendation for HMP YOI
Recommendation 10: The Governor of HMP, YOI, should review the roles and responsibilities of the Chaplaincy Service with regard to the information-sharing around safeguarding issues and provision of information to Serious Case Reviews.
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